The purpose of this study is to review and validate the Health and Safety Executive Management Standards Index Tool to assess stress-related factors among health care workers.
The HSE indicator tool in Cousins et al.'s study includes seven factors (Demands, Control, Managerial support, Work colleague support, Relationships, Role and Change) [12]. Similar to the Cousins et al.'s version, the same seven factors were extracted in the German and Indonesian versions of the HSE index tool [28, 29]. In Magnavita's study, six factors (Demands, Control, Support, Relationships, Role, and Elasticity) were evaluated [30]. Veronesi et al. developed an Italian version containing 7 factors (Demands, Control, Manager's support, Role, Peer support, Relationships, and Participation to the work organization) [31]. EFA results showed that HSE-DOSIT is a nine-factor structure in the samples of this study. This difference is due to the addition of 3 new factors (Cognitive structure, Individual context and Non-job factors) in the present studies. The findings of this study support the six factors in the study of Cousins et al (Superior support, Demands, Job control, Social support, Changes, and Relationships).
The distinguishing feature of HSE-DOSIT is its multidimensionality. So that in addition to measuring organizational and social dimensions related to workplace stress, it also includes individual factors related to the employee. An organization consists of a group of people who have different beliefs, values, cultures and challenges. In addition to the fact that these differences can affect individual strengths and weaknesses, they also affect the organizational space. Other evidence shows that personality affects the assessment and coping with stress [13, 32]. Therefore, according to the above and the findings of other studies [14], in order to facilitate targeted and effective interventions, individual and non-job related stressors were included in HSE-DOSIT along with organizational factors. The "Individual context" factor is a new dimension in HSE-DOSIT. "Individual context" evaluates employees' self-confidence and self-efficacy as significant individual characteristics in mental health. "Cognitive structure" is another new factor in this version. "Cognitive structure" evaluates how the employee understands and reasons about job performance and superiors. The third dimension added in HSE-DOSIT is "Non-job factors" and deals with family and financial challenges. In general, the above three factors in this version have sufficient reliability and validity. Three new dimensions assess non-work and self-related factors that can engage health care workers at work.
Although in the first version of the HSE “Demands and Role” were separate [12], in the HSE-DOSIT “Demands and Role” were combined in the EFA. Considering that most of the items were related to "Demands", this name was chosen for the integrated factor. Considering that the nature of "Role" and "Demands" are combined with expectations, it seems that these two factors were not conceptually distinct for the participants of this study. Therefore, "Demands" in this study examines work patterns, evaluations, workload and expectations of the organization and clients. This dimension deals with how to create and apply changes. In the revised Italian version (MS-RIT), “Manager support and changes” were combined and introduced as “elasticity” [30]. Boyd et al developed and evaluated an Irish version (ROL-MSIT) [33]. The Irish version also integrated "Changes and Manager support" and was named "Flexibility". In the HSE-DOSIT, similar to the British version [12], “Manager support and Change” were extracted independently. This can be due to the change of some items and cultural and social differences. In Iranian society, psychological support from superiors is considered important. On the other hand, HSE-DOSIT deals with how to create and implement changes in the workplace with the view that changes are an integral part of the workplace. "Job control" measures a person's independence in performing tasks in line with the expected work. Among the identified factors, although "Job control" included only 2 observational variables, both variables had a factor loading above 0.7 and the correlation between them was above 0.7 [34]. It seems that these two items were enough to measure "Job control" among the participants of this study. This study was conducted during the outbreak of COVID and vaccination against the disease. At that time, health care workers were one of the leading groups in the fight against COVID, and all activities were carried out according to clear instructions and rules that were applied by higher levels. Therefore, probably the samples of this study did not consider some items related to occupational authority and control to be meaningful. However, further investigations are needed in future studies to develop this dimension. In HSE-DOSIT, "Relationships" examines tensions and individual capabilities in workplace communication. A number of items in this dimension are similar to Cousins et al.'s study [12]. In addition, one item was added to this dimension to assess the employee's communication skills in challenges.
Cronbach's alpha and McDonald Omega coefficients and intra-class correlation coefficient (ICC) coefficients showed that HSE-DOSIT has acceptable reliability in the Iranian sample. This finding regarding "Social support" is cautiously reported, it may be necessary to revise the items related to colleagues and family or separate the two.
Strengths and limitations
The distinguishing feature of HSE-DOSIT is its multidimensionality. So that in addition to measuring organizational and social dimensions related to workplace stress, it also includes individual factors related to the employee. However, the current version of HSE-DOSIT has limitations. For example, the participants of this study were limited to health care workers working in primary health care centers and did not include other administrative or therapeutic departments. In addition, to measure the validity of the introduced instrument, it is necessary to compare the results with other validated instruments and report concurrent or criterion validity. As this study lacked this analysis, future studies could conduct concurrent or criterion validity.